All Monday-Friday admissions from 8 am until 4 pm will go through the Chief Resident of the day. All other admissions are called to the long call G2. G1 residents need to know each patient on the team, including patients being cared for by students. G1s need to meet each student patient on the day of admission, know the important aspects of the patient’s history, physical, and diagnostic exam, and understand the plans. G1s do not need to repeat the history and physical to know these elements. Sometimes, G1s and G2s could see a student patient together.

Short Call 1:

1. Admits from 8 am - 3 pm Monday through Friday except official holidays.
2. Limit of 2 admissions per team or team size of 12 by 3 pm. If team size is less than 5, the team will be open for 3 admissions.
3. Short call 1 may admit ICU patients at the discretion of the Chief Resident.
4. Chief Residents will determine the order of short call admissions based on overall workload of the two teams.

Short Call 2:

1. Same as Short Call 1 except Short Call 2 does occur on weekends and holidays for the G1. On these days the admission limits are the same but the G1 is in the hospital from 8 am until 6 pm, when the night float arrives. On weekends/holidays the supervising G2 for Short Call 2 admissions is the long call G2, not the team G2. For student patients on weekend S2 days, the G1 on the team needs to know the patient more extensively than on a weekday S2.
2. Short Call 2 may admit ICU patients at the discretion of the Chief Residents or the Long Call G2.
3. The Short Call 2 G1 carries the Doctor Blue beeper from 8 am until 4 pm Monday - Friday and from 8 am until 6 pm on weekends and holidays. The beeper is handed off to the night float G1 on all days.
4. On weekends and holidays it is important that the short call 2 G1 gets two admissions and gets them reasonably early so the first two admissions of the day should go to the short 2 team, unless the short call 2 G1has pressing problems on the team that require immediate attention.

Long Call:

1. 8 am to 8 a.m.; Generally one admit is taken prior to 1pm, depending on admissions to the short call teams, specific limits and discretion of the Chief Residents in consultation with the long call G2
2. Limit of 5 admissions per team or team size of 12.
3. G1s must leave the hospital by 11pm to be in accordance with duty hour limits. Admissions after 11 pm are cared for by the G2.
4. Long Call G2 will handle Medicine Clinic patient phone calls.

Overfills:

Only established clinic patients will be taken beyond the above limits.  If a clinic patient is admitted beyond the daily limits, the long call G2 should do the admission.   If more than one medicine clinic patient is admitted beyond the limit, orders may be placed in Excellian, and the patient held over for one of the on-call teams to admit the next day.  This should be done in consultation with the staff on call, provided the patient is not in the ICU and is relatively stable.

One of the key components of the Internal Medicine residency program at Abbott Northwestern Hospital is the inpatient resident’s service. This service consists of six teams, each with a second year and a first year resident, along with one or two University of Minnesota medical students.

Patients admitted to the resident service will be under the supervision of the admitting faculty.  The vast majority of admits will come from the ANW hospitalist service, COC, and Medicine Clinic faculty. The role and responsibilities of both full-time faculty and admitting faculty members are the same when they are serving as a patient’s attending physician. The familiarity of attending physicians and residents with each other is important for building trust and communication as well as for the role modeling and other informal education that the faculty bring to the program. Each attending physician must be a committed, enthusiastic, and dedicated physician who is medically competent and an effective team leader and teacher.

Appointment of physicians to the admitting faculty is made by the Medical Education Department in consultation with the Internal Medicine Graduate Medical Education Committee. Continued participation in this program is not a function of an attending's popularity with the residents but is based on a careful, evaluation of his or her commitment to teaching and supervising residents,  overall competence as an attending physician, and evaluations. Appointment to the admitting faculty is a strictly educational matter and has no impact on any other credentialling issues at the hospital.

1. The American Board of Internal Medicine requires that "All faculty members must be certified by the ABIM or present equivalent credentials or experience". Each member of the admitting faculty will be an internist or internal medicine subspecialist who admits at least 12 inpatients per year to Abbott Northwestern hospital. In addition, admitting faculty need to be present in the hospital throughout the day, and are members of the ANW Hospitalist group, ANGMA faculty, and must be readily available to the residents on the case.
2. The attending is usually responsible for informing the patient or family about the involvement of the residents as part of the care team. Patients or families may refuse to be involved with the residents' service. There should not be a different standard of appropriateness for nights and weekends. Admission to the residents’ service is accomplished by telling chief resident or G2 on-call after 4pm weekdays and on weekends that the patient should be on the residents’ service. Either of these two will know if the residents’ service is closed because the maximum admission load has been reached.
3. Appropriate patients are patients who need an evaluation and some active medical care. However, appropriate does not mean only rare disease or critical illness. The residents' service also needs common internal medicine problems. Patients who have already been evaluated and are being admitted for a scheduled procedure or for one day therapies are rarely appropriate for admission. The residents’ service should not be used to perform elective, routine pre-procedural/pre-therapy histories and physicals.  Internal Medicine consults should primarily go to the consult service when available, but on weekends occasional consults may be placed on the resident teams.  An occasional patient not initially admitted to the residents’ service may develop new problems or diagnoses that make the patient appropriate to be transferred to the residents’ service. The attending should call the chief residents (during weekdays) or G2 resident on call (nights and weekends) to discuss such a transfer.
4. The attending is the leader of the patient care team. This leadership is exercised through a commitment to appropriate supervision, discussion and the use of medical evidence and critical thinking. Attendings must be willing to take the time to explain and support their conclusions and plans, often with support from the medical literature. An attending should also value the thoughts of the residents and should help the residents cultivate a healthy skepticism regarding medical knowledge and practice.

The Chief resident or long call G2 will notify Admitting and the ER that the Resident Service is closed when the ordinary limits have been reached. At the discretion of the chief residents, an occasional patient will be admitted to the Resident Service the next day. This will be considered the next day on a case-by-case basis. If a long-call G2 thinks there are unusual circumstances prompting closing of the service, the G2 should discuss this with a staff physician on call.

Bounce-Backs

A patient is "bounced-back" to a previous G1 if readmission occurs within two weeks of discharge and if the G1 had cared for the patient for 48 hours before discharge. The bounce-back occurs on the morning after readmission. The bounce-back dose not count as a new admission for the previous G1 because a full admission workup will have been done by the admitting team. A bounce-back will not occur if a G1 is leaving the service in less than 48 hours from the time of bounce-back or on a weekend day if the G1 is not rounding that day.

Teaching conferences, either case-conference, or didactic lecture, are held daily. Residents should make every effort to attend these conferences. It is the requirement to attend at least 60% of the conferences each year. If a resident does not achieve the 60% target, it will be raised during regular meetings with the Program Director. Reasons for not attending will be explored, and if the conference attendance does not improve and meet the 60% threshold, adverse consequences, including a negative evaluation in the permanent file, or possible failure to advance years will be considered. Failure to designate attendance at the conference is not a legitimate excuse, and will be considered an absence.

Residents may attend conferences of approved scientific or educational merit. This time is not considered PTO, but residency education time. Money is available only for those presenting original research at such meetings. The program will pay for travel, food, and lodging for the days required to travel and present. Expenses for additional days to attend the conference will need to be paid for by the resident. The Program Director must evaluate all requests to attend conferences.

Counseling services are available, and if at any time you feel these would be helpful, you are asked to contact your advisor or the program leads. In addition, counseling may be recommended based on performance or assessment of the faculty and program director, In the unusual event of significant performance deficits that would be amenable to counseling/therapy, or neuropsychiatric behavior in need of professional treatment, this therapy may be mandated.

Both short-term and long-term disability coverage is provided through the Allina benefits program...

Short-term Disability:

Short-term disability is provided at 100% of pay for medical leave (5th day through 90th day), or maternity leave (5th day through 42nd day for normal delivery or 5th day through 56th day for C-section delivery).

Long-Term Disability:

Long-term disability is provided according to the level of coverage selected during initial employment or open enrollment: 0%, 45%, 60% or 65%. It is important to understand that these disability coverages apply to financial compensation for time away from the program, but do not change ABIM training time requirements.

In the event of a natural or man-made disaster that would seriously jeopardize the ability of the hospital and residency program to function, notification via the hospital’s disaster (orange alert ) policy and chain of command will be made to the Program Director and chief residents. Depending on the need for assistance, including medical triage, certain residents may be asked to aid victims or report to the emergency room. Initially non-ward residents from consult rotations would be contacted and instructed on specific duties. Ward residents would be the last to be enlisted for help.

In the event of a disaster on a scale that would not allow the program to function, the Program Director and program leadership would make all attempts to place residents at local and regional programs to facilitate continuation of training as allowed by the ACGME. Once the necessary measures are taken to remediate the hospital’s disaster situation, residents would continue training at Abbott Northwestern. While the goal would be to have all residents return to complete their training, his would depend on the level of function attained by the hospital post-disaster.

G2s are primarily responsible for all discharge summaries, especially during the first half of the year. This may become a shared responsibility later in the year. The G2 should ideally complete the discharge summary on the day of admission, and certainly within 24 hours. Discharge summaries should be done using either the discharge summary or discharge letter template in Excellian. Residents are responsible for discharge summaries on patients discharged within 48 hours of 8 am on a G2 switch day. However, ideally discharge summaries should be done on the day of discharge. If this is not possible, the staff should be notified on the discharge day, so they may complete the summary or OK completion by the resident the next day. Be certain to insert the appropriate attending physician's name (not group), and any referring physicians needing a copy. Residents should use the link at the end of the discharge summary to cc copies to any physicians who should receive one, rather than routing to better ensure the document gets to the appropriate physician. If the primary physician is not already identified, he or she should be, and the note cc’d to that physician. Note that if the discharge summary is not done on the day of discharge, there needs to be a progress note in the chart for that day.

The ANW Internal Medicine Residency encourages its residents and staff to fully disclose medical mistakes to the Residency Council, program leadership, or advisor within twenty-four hours. No punitive action will be initiated based on information gained as a result of self-reporting of medical mistakes.

The rationale for this policy includes the following:

• facilitate appropriate disclosure of medical mistakes to patients
• improve patient care
• help develop an institutional definition of medical mistakes
• give credence to the claim of physician self-governance
• identify and correct systems errors which permit medical mistakes
• align patients' and physicians' expectations of health care
• promote physician self-care and ethical maturity

The Allina dress code policy applies to all employees, including residents, and specifics can be found under Human Resources link on the AKN website. Essentially residents should be conservative when using cologne, makeup, hair styling or coloring. Remember your outward appearance greatly affects your relationships to patients. Residents may wear scrub clothing when on-call or on rotations where procedures are to be done. Otherwise residents should wear appropriate clothing per the Allina policy with the white coat provided. It is the responsibility of the resident to keep his or her white coat cleaned.

• Residents are limited to 80 hours of in house duty per week, including in-house moonlighting.
• All residents receive 1 day off in 7 and this will occur on a weekend day on all rotations. For ward G2s, if long call falls on a Saturday, the day off will be the following Tuesday.
• Ward rotations: Long call is every 6th night.
• On long call, G1 residents are to leave at 11 p.m.; further work is performed by the G2 resident. The G1 returns by 8 am the post-call day. No new patients are admitted on the post-call day.
• Clinic is scheduled on a fixed day in the 6 day cycle and does not fall on the post-long call day.
• G2 leaves hospital by 2pm the post-call day . If it is anticipated that this will be problematic, the G2 is to notify the chief residents, who will make arrangements for coverage as needed.
• Residents are to call the post-call G2 on the weekends to help with seeing patients to ensure the post-call G2 can leave by 2pm.
• Team caps are 12 patients per team. No new admissions will be taken beyond these limits on either short or long call.

Non-ward rotations:

1. Night float: Night float shifts are from 4 to midnight and midnight to 8 am Monday through Friday. The day off is either Saturday or Sunday, depending on the night float shift worked for that week. Weekend night float occurs either Saturday or Sunday night from 6 pm to 8am. Each second year resident will do one night float block, and each third year resident may be scheduled to cover some vacation time for other night float residents. See specific night float schedule for details of shifts.
2. During G2 and G3 non-ward rotations, night float shifts are Monday through Friday and generally weekend shifts are covered by first year residents, although a few exceptions exist.
3. For subspecialty and outpatient rotations, see specific rotation description for further details. Some shifts may have different start times, but are Monday through Friday.
4. In-house moonlighting may be performed during all G3 rotations, and G2 non-ward blocks, and is subject to the 80 hour weekly limit. (See separate M1, M2, and M3 policies).

Duty Hours Verification:

All hours and rotation schedules will be verified in the RMS system via New Innovations. This system is an online verification system, where residents will login at least weekly to verify their rotation schedules, conferences, and time off. Any modifications are made at that time. Rotations are pre-scheduled and every attempt at accuracy of schedules is made. Residents should verify duty hours on a weekly basis and be sure to double check the accuracy of schedules. On ward rotations, since the weekend day off can vary, residents should change the day off to reflect accurate hours. This system is used to track hours for government reimbursment and monitoring of duty hours.

Evaluations are done electronically in the “E-Value” on-line system. Residents are expected to complete an online evaluation at the end of each rotation as indicated. On ward rotations, first and second year residents will evaluate each other, and each will submit an attending evaluation, depending on the length of time spent with a teaching attending. You will receive an email requesting you to complete an evaluation at the appropriate time. It is important to do these evaluations in a timely manner, and progression /satisfactory evaluation in the resident file will be based in part on completion of evaluations. Ward G2s will also need to evaluate students at the middle and end of their rotation. Please note that all evaluations are considered, and are used for important feedback and improvement in performance, both by residents and staff. Comments remain anonymous in the E-Value system.

Resident performance and advancement will be based on (but not limited to) a composite of the following:

1. Faculty evaluation of performance on rotations in the 6 ACGME competencies. For G2s, this includes the ability to teach and mentor medical students.
2. Structured clinical evaluations, that include interviewing, physical diagnosis, counseling skills, evaluation of professionalism, and other competency areas. Many of these will occur in the G1 year.
3. Formal chart review evaluations of record keeping in Excellian, including H and Ps, progress notes, discharge summaries, and consults.
4. Formal evaluation of continuity clinic performance, including chart reviews.
5. Attainment of a passing score on step 3 national boards. For DOs, passing the comlex exam.
6. Formal evaluation of medical knowledge, critical appraisal skills, physical diagnosis, including heart sounds and ECG skills will be performed either by end of year testing or via periodic testing throughout the year.
7. Completion of scholarly project in the third year
8. Completion of rotation specific requirements, such as ICU presentation or testing.
9. Attainment of overall 60 % conference attendance.
10. Completion of in training exam in the G2 year. Note that scores are not used for resident advancement, but all G2s are required to take the exam.
11. Acceptable completion of required evaluations in the E-value system.
12. Complicance with duty hours verification.

All residents have twice-yearly meetings with the program director or associate program director, regular meetings with their advisors, and a summary evaluation is prepared at the end of each year. For jobs and fellowships, letters of recommendation may be requested from any faculty a resident wishes. A formal program letter, if requested, will come from the program director. At the end of each year, a group of faculty known as the clinical competence committee meet and formally assess and discuss each resident’s performance. Advancement or graduation from the program is considered, and any concerns or need for remediation, etc are brought forth. As per the contract, if non-renewal is being considered, that decision will be made by March 1st.

Hospital policy provides for a funeral leave-of-absence of up to three days without loss of pay for the purpose of attending the funeral of any of the following resident’s family members: Spouse, Parent, Parent-in-law, Child, Sibling, Grandparent. Such leave shall be the day of the funeral, the day before and after, unless different days are agreed upon between resident and the Program Director.

Grievances

Grievances of the Resident must be presented to the Program Director.  If not resolved to the satisfaction of the Resident, he/she must have the opportunity to present the matter to the GIMEC.

In instances where the grievance(s) is/are not satisfactorily resolved, the Resident must be informed by the Director of his right to present the issue(s) to the GIMEC.  In the case where the matter remains unresolved, the GIMEC will present the conflict to the Chief of Staff.  The judgment of the GIMEC will be reviewed by the Chief of Staff before determining if further action is necessary.

Graduate Internal Medicine Education Committee (GIMEC)

• The (GIMEC) monitors the performance and educational accomplishments of members of the housestaff as well as conducting the institutional review of the residency program.
• A Resident may grieve an action taken against him or her through the GIMEC.  A request must be made to the Director of Graduate Medical Education in order to have the Committee hear the grievance.
• Residents may also request assistance from the GIMEC in instances where a formal action has not been taken but a problem exits that cannot be worked out with the Director.

Probation

• Probation is an opportunity period for a Resident to bring his/her performance to a satisfactory level with the aid of more intensive counseling and monitoring.
• If the gravity or the frequency of less than satisfactory evaluations or other problems result in the assignment of Probation by the GIMEC, the Resident will be offered the opportunity to appeal to the GIMEC.  Should the Resident wish to appeal to the GIMEC, the Resident must make a request in writing to the Director.

Pursuant to such appearance before the GIMEC the following procedures will be followed:

• The Resident will be given written notice of the precise circumstances at least two weeks in advance of his/her appearance.  The Resident will be given an opportunity to appear before the GIMEC to present additional information, take issue with the Department’s decision, and/or call witnesses in support of his/her position.  He or she will be also given the opportunity to bring a representative of choice who may aid and counsel the Resident.   Since the GIMEC meets to investigate facts, and does not conduct an adversarial hearing, there is no cross-examination, and an attorney may not directly participate in questioning.
• Probation requires a majority vote of the GIMEC.
• The reasons for probation will be specified (i.e., the Resident’s specific actions or deficiencies that led to the recommendation of probation).  The conditions of probation (what the Resident will be expected to do differently), and the specific measures taken by the Program to help the Resident achieve these goals will be detailed.  A copy of this statement will be presented to the Resident.
• The length of probation will be specified, together with the various options that can occur following the completion of the probationary period.  A period of probation will usually be from 1 to 3 months, but may occasionally be for the duration of an academic year.
• If the GIMEC upholds the Resident’s appeal, then probation will be immediately terminated.  All documentation of probationary action will be removed from the Resident’s file.

Options After Probation

At the end of probation, the following may occur:

• Termination of Probation with a statement in the house officer’s record that the conditions of probation were satisfactorily resolved and the issues are not longer considered to be a serious problem.
• Continuation of Probation for an additional specified period of time, and a redefining of the problems and procedures to be followed below:
• Premature dismissal - Temporary suspension: If the GIMEC believes that the retention of a Resident would jeopardize patient care or welfare, or that the Resident would jeopardize patient care or welfare, or that the Resident should not be permitted to continue with his/her responsibilities for some other reason, the Resident can be temporarily suspended at once.  The Resident may then appeal, at his/her discretion, to the GIMEC, pursuant to the above procedures.  Such a temporary suspension may also follow a probationary period during which the Resident has failed to bring up his/her performance to satisfactory standards.
• The decision to discharge a Resident in the middle of the year must be agreed by a majority vote of at least 2/3 of the members of the GIMEC.  The minutes of the GIMEC, will serve as a means of the action undertaken.
• Under usual circumstances, the decision to prematurely dismiss a Resident will be taken after the Resident had been on probation.  Under unusual circumstances, the Director may feel that an abrupt decision necessitating premature dismissal of a Resident should be carried out without awaiting the normal probation process.  Under these circumstances, the Resident should be assigned a role which removes him or her from any responsibility for direct patient care, until the case can be heard by the GIMEC.  The Resident will thus be considered to be temporarily suspended, pending completion of the grievance procedure.
• The recommendation of the Director not to renew the Appointment of a Resident must take place no later than March 1st (or eight months after the start of the program) of the Academic Year.  Failure to inform the Resident of such a recommendation by that date must be treated as a premature dismissal.
• In the event that the GIMEC considers termination of an appointment in the middle of the year or non-renewal of the year-to-year contract, it shall insure that the above procedures include a notice and an opportunity to refute charges, take place prior to and during any decision-making meeting or meetings.

Withholding of Approval To Take Internal Medicine Boards

The withholding of approval to take internal medicine boards could result from the nature and/or frequency of the resident having received less than satisfactory regular period evaluations.

The Resident must be afforded an opportunity to grieve this action to the GIMEC.

Timeframe for Presenting Grievances to the GIMEC

Grievances may be brought to the GIMEC at any time.  However, delays of more than two weeks after an action is taken may interfere with the ability to remedy certain adverse actions.

The hospital pays for long distance calls only when the calls are directly related to patient care work. All other calls, including those related to fellowship and job search activities, should be paid for by each resident. If you need to make a long distance personal call at work, just let the office know. We will get a printout each month of the calls made from each of our phones along with the time, dollar amount, and phone number to which the call was made. You can then reimburse us for the call. It is not possible to make long distance calls from the call rooms or the residents’ lounge.

The full-time medical education faculty will contribute, without charge, to the patient care and education surrounding each patient during teaching attending rounds. The patients may be examined by the medical education faculty member during these rounds for teaching purposes. Additional discussions about patients between residents and the medical education faculty may occur informally or in formal conferences. All of these contributions by medical education faculty will be made rigorously and honestly, but with awareness that the attending is the leader of each patient's care and that medical decisions are often complex and difficult. In this teaching attending role, a faculty member is not necessarily the attending of record and does not document in the chart.

This policy mirrors that in effect for all faculty physicians and other members of the medical staff.  See also discharge summary guidelines above.

It is important to maintain medical records regularly, and this is readily done in Excellian.  Note that verbal orders should be electronically co-signed within 48 hours of giving the order.

A chart is considered delinquent when it is incomplete 30 days after discharge.  A letter will be sent to the resident notifying him or her of the delinquent chart, and if persistently delinquent next week, the resident’s parking card will be deactivated and the resident must personally pay for parking beginning 8 days after any chart becomes delinquent. When delinquent charts are completed, the parking card will be reactivated. Continued and repeated delinquency is considered a lack of professionalism, and will be addressed by the resident’s advisor, and program director if needed.  This may result in adverse consequences, including negative evaluations in the permanent resident file that could affect job and fellowship opportunities after residency.

In addition, it is important to be prompt in entering daily notes.  Note that all charting must be completed prior to leaving the hospital for the day.  This includes H and Ps, progress notes, and also discharge summaries that are needed for that day.

• Clinic patients are bounced-back to their clinic physicians’ teams if their residents are on the ward teams.
• Scheduled clinic patient admissions, where the admission or pre-op history and physical was done in clinic, do not count as admissions. The long call admitting team should only briefly see the patient and write a brief note. In other situations where the patient requires ongoing management by the admitting team, the patient should count as an admission. If a resident needs to admit a patient from clinic unexpectedly, he or she may do the admit note from clinic and count the admission from clinic. In general, however, the on-call team should admit these patients to allow the G1 to be part of the admission. Bounces or clinic patients should not be admitted to a post-call team.
• When a resident is on a non-ward team rotation (including night float rotations in the G1 year) but is on the campus, the resident should see each of his or her hospitalized clinic patient(s) at regular intervals during the hospitalization as “social” visit. This improves the continuity of the patient care and keeps the resident aware of what is happening with the patient. The admitting resident service team is responsible for notifying the off-ward resident of the clinic patient admission. The resident does not need to enter a note, but may do so at his or her discretion.
• Clinic patients admitted should be staffed with medicine clinic faculty during the day and on weekends. Staff evening and night coverage Monday through Thursday may be provided by medicine clinic staff or COC staff; consult the schedule for specifics.

The Program is required by the ACGME to know of all resident moonlighting, whether at ANW or at an outside site. This is to ensure that moonlighting does not negatively impact on a resident’s education. All moonlighting must be approved by the program director in advance.  Except in very unusual circumstances, the program will only allow moonlighting to occur at ANW in one of the three available voluntary moonlighting positions. These are only available to residents with Minnesota licenses. See separate detailed descriptions of these opportunities.  Residents on a J-1 visa permit are prohibited from moonlighting due to visa restrictions.  Please remember that moonlighting must not interfere with rotations, and limits on number of consults, etc, cannot be created.  If you are unable to perform full duties the-post moonlighting day, you must report this to the program director.  If a resident is deemed unable to perform duties satisfactorily post-moonlighting, he or she may be excluded from moonlighting. 

Updated: July, 2008

Pager 654-5829

The M1/House Officer (5pm -- 8 am) moonlighting position is open to G3s and off-ward G2s.

The M1 moonlighter does admissions for ANW Hospitalist service and limited admissions from the COC clinic pod of ANGMA seven days a week. The moonlighter is generally expected to take 5 admissions (option of 6) on weeknights and 6 admissions on weekends/holidays. All admissions are staffed via phone with the attending for G2s, and ICU admissions are staffed for G2s and G3s. The attending should be called at any time for questions or concerns, regardless of the nature of the admit or training level. The moonlighter will tally the number of admissions for each group (AHS/COC) on the schedule in the residents’ lounge. The moonlighter should also call 863-6851 and leave a message denoting the patients admitted overnight.

The M1 moonlighter is also the House Officer every night from 5 pm to 8am, and this role will be covered by the G2 on long call during the periods 8:00 am to 5:00 pm Saturdays and Sundays and official holidays.  The House Officer  is available on request by an attending physician (or Rapid Response team) to assist in the evaluation of acute situations which require the immediate attention of an on-site physician. The House Officer is also available to offer acute management of unstable patients while the attending physician or on-call physician is in transit to the hospital. The House Officer also performs death pronouncements and, on rare occasions, may evaluate patients without medical emergencies in order to determine how soon a more complete evaluation should occur.

This coverage is extended to all patients not followed by one of the six inpatient resident teams; calls regarding these patients must be directed to the teaching team or the "cross coverage" G1 as appropriate.

In an emergency, the House Officer may be called to see a patient before the attending has been notified. If the nursing staff asks for an emergency evaluation, they must document the situation and what conditions made them feel that an emergency evaluation was required. It is the responsibility of the nursing staff to contact the attending physician ASAP and inform them of the situation.

The M1 moonlighter takes all cross cover phone calls for the ANW Hospitalist Service from 11pm to 5 am Monday through Thursday (except on holidays).

Coverage responsibilities for a House Officer call include the following:

• Initial evaluation and assessment of the patient: This includes ordering and evaluating any tests, labs, or x-rays that are felt to be necessary. Typical examples would include STAT EKG, CXR, ABG.
• Treatment orders essential for the immediate care of the patient. Typical examples may include nebs, nitroglycerin, glucose, etc.
• After the initial assessment and stabilization, the House Officer must notify the attending physician. This should generally occur within 20 to 30 minutes.
• The House Officer will then document his/her evaluation, impression, and interaction with the attending physician in the medical record.
• Transfer of patient to the ICU if appropriate and required to stabilize the patient. Initial orders in the ICU can also come from the House Officer. Orders for vent settings would be a typical example. At this point, all further care of the patient is transferred back to the attending physician, allowing for transit time to the hospital if the physician is en route.

Once care has been transferred back to the attending physician it is his/her responsibility to:

• Follow-up on tests, labs, or x-rays ordered by the House Officer which were not part of the initial stabilization. Example: House Officer may have the patient intubated, but post-intubation ABGs should go to the attending physician.
• Communicate with appropriate consultants as needed.
• Resume care of patients needing ongoing management beyond initial stabilization.

The House Officer will not be expected to provide the following:

• History/physical or admission evaluations
• Non-emergent medicine consultations
• Daily rounds or progress notes
• Ongoing management or complete evaluation of a patient’s problem beyond what is required for immediate stabilization.
• Interpretation of routine EKGs and x-rays which can wait until morning
• Consulting consultants to evaluate a patient.
• Become involved in "family situations" and deal with social issues, unless a patient unexpectedly decompensates and DNR status needs to be addressed before the attending physician can arrive at the hospital.

Other:

The House Officer may be requested by the attending to interpret emergent/urgent EKGs and after-hour x-rays without examining the patient. This interpretation should also be documented in the chart and communicated to the attending.

The House Officer may occasionally be asked to assess a patient for a condition that would appear to be non-emergent, to help the attending determine whether more complete assessment or consultation can wait until morning.

Falls will be treated as any other medical condition. The attending physician must be notified first and if appropriate may request evaluation by the House Officer.

Emergent situations requiring procedures beyond the skill of the house officer will be addressed by consulting the appropriate specialist after conferring with the attending physician. This may include involving the surgical resident to help manage lacerations. Simple steri-stripping is considered within the role of the House Officer.

The House Officer may be asked to provide brief medical clearance allowing implementation of a psychiatric 72-hour hold. Federal law requires that all patients placed on a 72-hour hold be cleared medically within one hour. The request for the hold will come from the attending psychiatrist, but the House Officer may be asked to briefly clear the patient. This will only occur during evening and night time hours.

The House Officer may also be asked to provide evaluation of psychiatric patients who are restrained.  Federal law requires a physician visit every 8 hours to document stability and prevent untoward problems as a result of restraining patients. The resident should document patient stability on the checklist provided.

Patients on psychiatric stations requiring immediate transfer to a medicine bed may be followed after transfer by the Hospitalists, but both the patient’s attending on the psych floor and the on-call physician for the Hospitalist service should consent to transfer. This would also apply to an unassigned patient needing emergent transfer back to the hospital.

Responsibility & Liability:

It will be remembered by all that the House Officer is a resident functioning under supervision as the hands, eyes, and ears of the attending who cannot personally assess the patient. From a liability standpoint, therefore, it is expected that the House Officer shall communicate findings to the attending physician who will assume responsibility for care and decision making including the decision to obtain (or not obtain) help from a consultant when appropriate.

This consultant may be an internist if the attending is of another specialty; in some circumstances, it may be appropriate for the House Officer to suggest consulting a staff internist and discuss the case with this person. If the attending physician is unfamiliar with the Abbott Northwestern medical staff, it may be appropriate for the House Officer to suggest consultants in other specialties.  If the situation at hand requires consultation by the intensivist service, this may be initiated by the house officer in cases where the attending is unable or unwilling to assume the role of managing the patient’s acute illness.

Updated: July 2008

Pager 654-6157

The M2 moonlighting position is open to G3s and off-ward G2s. This position runs from 5 pm to 8 am every Friday, Saturday, and Sunday.

The M2 moonlighter takes all cross cover phone calls for the ANW Hospitalist Service from 11pm to 5 am  Sunday & from 11pm to 8 am Friday , Saturdays, and Holidays. In addition, the M2 moonlighter does admissions for the ANW Hospitalist Service in an alternating fashion with the M1 moonlighter on weekends and holidays. In addition a limited number of admissions may be taken from the COC staff on call.  Like M1, the M2 moonlighter is not obligated to take more than 6 admissions on Friday/Saturday/Sunday/Holiday nights, and will not be paid for doing any more than 6 admissions. All admissions will be staffed with the appropriate attending for G2s, G3s need only staff ICU admits. However any moonlighter should call staff for questions or concerns at any time. Call the answering service and ask which attending is on call for that night, as posted schedules can change. The on-call staff can then be paged directly. Ongoing, active issues of patient care from the prior evening are best communicated to the attending the following morning.

There is in-house staff coverage for the ANW Hospitalist service Monday through Thursday generally 24 hours.  The in-house staff will assign admissions to the moonlighter during this time.  There will be one staff  “on-call” and is responsible for any admission over the moonlighter’s six.

The M2 moonlighter will record the number of admissions from each group on the schedule in the residents’ lounge, and call 863-6851 to report the admissions to the Hospitalist service so they will be seen the next am. 

July 2008

Pager: Resident personal pager

The M3 moonlighting position is open to all eligible G3s and G2s, including those on ward rotations. This position runs from 5 pm to 11 pm seven days a week.

The M3 moonlighter takes telephone calls regarding patients followed by the Minneapolis Cardiology Associates (MCA) and nursing station calls for the ANW Hospitalist service patients. This position can be filled from home and the moonlighter will not be required to come to the hospital for patient care.

Calls from nurses regarding patients for whom MCA serves as the attending physician and cardiology-related calls on patients for whom MCA serves as consultant will be routed through the MHI answering service. The M3 moonlighter will be paged directly on his/her personal pager.

Patient care issues that cannot be adequately managed over the telephone can be referred to the House Officer or the on-call cardiologist as appropriate. The M3 moonlighter should not be involved with patients who have not yet been seen by a cardiologist.

M3 moonlighters also take hospital cross-cover calls for the COC and ANW Hospitalist Group  from 5-11pm.  The calls should be handled similar to the Cardiology calls, with more complicated calls being deferred to the in-house staff.  The M3 resident should keep track of the calls separately and record them in the space provided in the resident lounge computer.

This position will be compensated on a per-phone-call basis. The number of phone calls will be determined by counting the number of pages. A conversation that requires the M3 moonlighter to place another call to an in-house physician would still be counted as one call. A page from a station that results in patient care via phone for three patients would be counted as three calls, however. The M3 moonlighter will record the number of calls on the schedule in the residents’ lounge. This is necessarily on the "honor system" with the realization that inconsistencies in number of calls can be investigated by having the MHI operator also tally pages if required.

Parties making changes to the M3 moonlighting schedule will be required to report the change to the MHI operator, to ensure they have an accurate schedule available to them with the proper phone number to call. The operator can be contacted at 863-3663.

Paid elective rotations may be taken away from the hospital during scheduled elective blocks in the G2 and G3 years. These rotations may be taken anywhere in or out of the country. The educational merit of the rotations must be approved by the Program Director to assure that the rotations count toward Board certification.  In addition, a detailed schedule will need to be completed and approved by the Program Director, with a copy given to the medical education office.  During the G1 outpatient block, research or subspecialty rotations of particular merit may be done, but the same guidelines for other electives apply and rotations will need to be approved in advance by the Program Director.

During elective rotations in the Twin Cities, G2 and G3 residents will continue to go to their continuity clinic. During rotations outside the Twin Cities, continuity clinic will be canceled. To allow this to happen the clinic staff and medical education office must know a minimum of three weeks in advance about the elective rotation.

During either elective or required off-campus rotations, if the consultant that a resident is working with is to be gone, and a half or whole day schedule is cancelled, the resident is expected to be in the hospital reading or working on other projects. The resident may not just stay home and read. If the resident wishes to take the time off, the medical education office must be notified.

PTO is any time that a resident is away from assigned responsibilities. The reason for the absence does not matter in terms of fulfilling ABIM training requirements. Whether illness, maternity/paternity leave, or acts of nature (blizzards), a day away from training is a PTO day.

G1 PTO:

• One month (22 work days). One week will be scheduled in each of 2 night float blocks, and the remainder will be taken from non-ward rotations.
• No more than 5 working days should be taken from any one rotation.
• Time off the ICU rotation should be scheduled at the start of the rotation, and generally should be a week at a time.

G2 PTO:

• One month (22 work days). In addition, the following hospital holidays will also be observed: July 4, Labor Day, Thanksgiving, Friday after Thanksgiving, Christmas Day, New Year’s Day, and Memorial Day. If a G2 is on long call on any of the following days, two replacement PTO days are earned: July 4, Labor Day, Thanksgiving, Friday after Thanksgiving, Christmas eve, Christmas Day, New Year’s Day, Memorial Day. If a G2 makes rounds for a ward team (whether post-call or not) on any of the above days, 1 day of PTO is earned. If additional PTO is needed, it will be taken from the G3 year PTO. A resident covering a call day for another resident will earn 2 days of PTO, and another day for post-call rounding if on the weekend or holiday.
• All G2 PTO is taken during non-ward blocks. To allow for appropriate coverage and clinic scheduling, PTO must be scheduled (or changed) 3 weeks in advance.
• Residents will complete all available medical records before leaving on PTO of more than two days.
• Any time away from work (more than 1/2 day) of which the Medical Education office is not aware or informed will be counted as 1.5 times the time gone (1 day = 1.5 days PTO).

G3 PTO:

• G3s receive one month (22 workdays of PTO) In addition, the following hospital holidays are observed: July 4, Labor Day, Thanksgiving, the day after Thanksgiving, Christmas Day, New Year’s Day, and Memorial Day. Note that any unused PTO days at the end of the training program will be forfeited and cannot be paid out as additional salary.
• To allow for appropriate coverage and clinic scheduling, clinic PTO must be scheduled (or changed) 3 weeks in advance.
• PTO must be cleared with the Medical Education Office and the appropriate section head. Any unapproved PTO will be charged at 1.5 times (i.e., 1 day = 1.5 days).
• No more than one week of PTO should usually be taken from any one subspecialty rotation.
• Residents should not save all PTO for the end of the year.
• Residents will complete all available medical records before leaving on PTO of more than two days.
• G3 residents will cover the NIP Clinic for G2s on PTO. This will be shared equally amongst the G3s
• G3s will also cover for the G2 on Tuesdays when the long call team was on call the previous Saturday. This will be scheduled at the beginning of the year and divided among the G3s.
• Residents will receive up to 3 days leave (total for 3 years) to facilitate job or fellowship interviewing. Additional time needed would have to be taken out of PTO.

A resident may be excused for a personal appointment without losing any PTO or training time. If at all possible, appointments should not be scheduled during the work day to minimize impact on training. The best option is to try and schedule the appointment later in the afternoon or first thing in the morning. G2s should try and schedule appointments on post call days if possible. Ward service G1s will need to work out the best time with the team’s G2.

For all appointments during workday hours, a resident must notify the Medical Education office beforehand. The nature of the appointment does not need to be disclosed — only the time the resident will be gone. This is not meant to "police" anyone, but only to allow the office to tell anyone looking for the resident that he or she is unavailable. This same level of notification is expected of faculty physicians as well.

Objective drug information is best provided by sources other than drug companies.  Accordingly, pharmaceutical representatives are not allowed to meet with staff or residents.  In addition, no gifts are accepted by staff or residents from drug manufacturers.  All Allina drug purchasing and additions to the formulary is done without outside influence via the Allina System Formulary Committee. No drug samples are provided in the medicine clinic or COC clinic.  Patients are best provided generic medications whenever possible, and are referred to pharmacies that provide low cost generic medications, such as Target and WalMart.

1. Each patient will be carefully evaluated by the residents’ service team in an appropriate and timely manner. The full evaluation of the patient will be completed by the G1 resident or the medical student and the history and physical entered into the electronic medical record. G2 residents will also enter an admission note that contains any corrections or additions to the G1 note or will be a complete admit note on student patients. The attending or covering partner will be called by the G1 or G2 resident as soon as the initial evaluation is complete. In most situations, the G1 and G2 will have discussed the case and will have agreed on their plans for the patient. However, during some particularly busy times, the G1 will call the attending without discussion with the G2 so that patient management is not delayed. The residents and attending will discuss the patient and reach a consensus about the further management of the patient.
2. The residents’ service team will follow each patient closely and completely and will enter timely, and accurate notes detailing their findings, thoughts, and plans. The attending delegates responsibility for patient management to the resident team but must be involved in important decision making. While the definition of important may vary from attending to attending, the residents should not wait for concurrence by the attending before initiating routine diagnostic and therapeutic measures. The team will speak directly to an attending or covering partner whenever an important change in patient condition occurs (e.g., transfer to an ICU or onset of new GI bleeding). For most situations, attendings and residents should be able to communicate through their notes in the chart. However, residents should call an attending to discuss pressing and important patient care decisions rather than wait for routine written communication the next day. Residents will read and respond to other physicians' notes. Suggestions will either be implemented or discussed further with the appropriate physician.
3. Residents will perform the basic procedures required by the ABIM (predominantly obtaining body fluids for analysis) when the procedure is indicated for one of their patients. A resident may opt to refer the procedure to the procedure team, Residents should be supervised by a more senior resident or staff physician who has appropriate expertise in the procedure until the resident has acquired the skill to perform the procedure independently. Residents will track their procedures in the E-Value system. Residents are not competent to perform a procedure independently until they have successfully completed a predetermined number of each kind of procedure. A resident may be asked by nursing staff to provide evidence of performance of the minimum number of procedures required to perform them independently. The required number of procedures are on the residency program website.
4. The residents are considered full partners in the care of the patients and are to be involved with patients and families in discussions of all issues. The residents will not reach final decisions about important issues such as limitations of care without discussion with the attending. Residents should appropriately initiate discussions about new diagnoses and treatment options but only when they are sure of the completeness of their knowledge and when they are aware of the attending's thoughts about the patient care.
5. The resident service teams will continue to care for their patients until they are discharged from the hospital since the activities related to discharge are very important. The discharge decision, like all important decisions, should be reached after discussion between the residents and the attending. An infrequent patient may resolve all medical problems and be transferred to a non-medical floor such as psychiatry or obstetrics. For such patients, it may be appropriate for the residents to sign off the case, but only after discussion with the attending. Otherwise, the sign-off option is intended only for situations of major conflict with patients and families where the presence of the residents is detrimental to patient care. The residents should sign off these cases only after discussion with the attending and a chief resident or medical education faculty member. Differences between residents and attendings should be resolvable with discussion, sometimes with the additional input of chief residents or medical education faculty. The residents are responsible for all of the discharge documentation and arrangements for each of their patients. Accurate and timely discharge summaries will be completed by the senior resident on each case, with copies directed to the attending and any referring physicians via the electronic medical record (see separate policy).

Sexual harassment is not tolerated and is taken very seriously.  It is important to be aware of one’s own behavior and how it may be interpreted by another individual.  What may seem innocent could be perceived as harassment to another person.  This can be true in situations of touch, such as hugging, even when it is not intended in a sexual manner.  If you ever feel you are experiencing sexual harassment, this needs to be reported to the Program Director immediately, and the appropriate steps will be taken in conjunction with human resources according to Allina policy.

The ABIM allows a total of three months of the 36 months of required residency time to be time away from training. This time away includes PTO time and any medical disability. Pregnancy leave is considered a medical disability by Federal Law. Our PTO time goes to the limit of the three month allotment. Any time beyond the PTO allotment must be made up for ABIM certification. It is important to note that the ABIM requires that all training must be completed by August 31 of any year in order for a resident to be a candidate for the August offering of the ABIM certifying exam.

When a resident has time to be made up because of leave, especially if it is ward time, that resident will be the first asked to cover time for a resident unable to perform duties because of illness, etc. This may even be long call. This happens sporadically and usually with little notice, and it is expected that residents with time to make up will be available to cover these days at least some of the time. All efforts must be made to be available when asked.

When ward time is missed because of leave, it can be expected that up to half of the time made up will be ward time, depending on the subsequent need for coverage.  The time made up may include coverage for a resident in a year behind; eg, a G2 may be asked to cover ward time for a current G1 if that G2 missed time out of the G1 year.

1. A system is in place that gives each resident one day off every week while on ward team rotations. A G3 will be assigned rounding duties on one weekend day where necessary to accomplish this. When the G2 is on long call on Saturday and post-call rounding Sunday, the following Tuesday (G1 clinic day) will be a day off for the G2. It will be covered by a G3 from a subspecialty rotation. This day off will not count against the resident's accumulated PTO days. When a switch to or from a different block occurs during this cycle, this day may not be an off day, depending on whether or not the G2 has one day per week off.
2. A member of each team must be in the hospital through Sign-out Rounds (4:30 PM) each weekday. Since the G1 from the long call team has guaranteed sleep because of the night float system, and because of program requirements, the G2 must leave the hospital by 2 PM the day following long call, while the G1 stays through Sign-out Rounds. Help will be provided as needed by the chief residents or staff on patients that become unstable or need ongoing attention. On clinic days for either the G1 or G2, the non-clinic resident is the one who must stay until 4:30. When the G2 is post-call on weekend days, the remaining residents will contact that G2 and help see that teams' patients as needed to allow the G2 to leave by 2 PM. The smallest teams should provide the most assistance.